pat gastrointest quirurgica

8/22/2019 Pat Gastrointest Quirurgica

1/10

Review

Surgical gastrointestinal disorders during pregnancy

Sareh Parangi, M.D.a,*, Deborah Levine, M.D.b, Antonia Henry, B.A.a,Nina Isakovich, B.A.a, Susan Pories, M.D.a

aDepartment of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USAbDepartment of Radiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA

Manuscript received July 24, 2005; revised manuscript April 21, 2006

Abstract

All gastrointestinal (GI) disorders can present during pregnancy, and in fact 0.2% to 1.0% of all

pregnant women require non-obstetrical general surgery. All of the clinical decision-making skills of the

experienced surgeon must come into play in order to make the correct therapeutic decisions whenevaluating the pregnant patient with a GI disorder that potentially requires surgery. While in general the

principles of diagnosing and treating a pregnant woman with an acute surgical abdominal problem remain

the same as those governing the treatment of the non-pregnant patient, some important differences are

present and can pose problems. As a general rule the condition of the mother should always take priority

because proper treatment of surgical diseases in the mother will usually benefit the fetus as well as the

mother. 2007 Excerpta Medica Inc. All rights reserved.

Keywords: Pregnancy; Gastrointestinal diseases; Surgery; Fetus

All gastrointestinal (GI) disorders can present during preg-nancy, and in fact .2% to 1.0% of all pregnant women

require non-obstetrical general surgery [1]. While in generalthe principles of diagnosing and treating a pregnant womanwith an acute surgical abdominal problem remains the sameas those governing the treatment of the non-pregnant pa-tient, some important differences are present and can poseproblems. As a general rule the condition of the mothershould always take priority because proper treatment ofsurgical diseases in the mother will usually benefit the fetusas well as the mother.

Various anatomic and physiologic changes occur duringnormal pregnancy, which can alter the presentation of con-ditions that require surgery: anatomic displacement of theintraperitoneal organs by the gravid uterus, decreased ve-

nous return due to pressure exerted on the inferior vena cavaby the enlarging uterus, increased cardiac output and heartrate, physiologic anemia, leukocytosis and tachycardia, de-creased gastric motility, increased gastric acidity, increasedminute ventilation, and decreased functional residual capac-ity. Diagnosis can be difficult as the enlarged uterusstretches the abdominal wall and compresses the viscera,which results in a diminished response to peritoneal irrita-

tion and altered or referred pain perception, making local-ization of the etiology of the pain more difficult. In addition,

various signs and symptoms that normally occur duringpregnancy such as morning sickness can be confused withsymptoms of acute GI disorders, such as nausea, vomiting,abdominal pain, and dyspepsia.

Proper evaluation and treatment of the pregnant patientrequires good clinical acumen, knowledge of the physio-logic changes of pregnancy, as well as the most common GIdiseases affecting pregnant woman. A clear treatment planthat avoids procrastination can be made after careful reviewof the history, a physical examination performed with thegravid uterus in mind, and judicious use of radiologicstudies. If imaging is necessary, sonography should bethe screening modality in most cases, and magnetic res-

onance (MR) imaging can be used in complicated cases.Imaging studies that require radiation such as radiogra-phy and computed tomography (CT) can be reserved forthose cases where ultrasound and/or MR imaging areinsufficient, are difficult to interpret, or are unavailable. Itis important to know the radiation doses for tests that areordered. The estimated dose to the uterus/fetus from aplain film of the abdomen is 250 mrad (2.5 mGy). For CTof the abdomen, the estimated dose to the uterus/fetus is3000 mrad (30 mGy) [2]. Fetal exposure can be limited insome cases with use of lead shielding of the maternalabdomen.

* Corresponding author. 330 Brookline Ave., Stoneman 934, Boston,

MA 02215. Tel.: 1-617-667-2442; fax: 1-617-667-4056.

E-mail address: [email protected]

The American Journal of Surgery 193 (2007) 223232

0002-9610/07/$ see front matter 2007 Excerpta Medica Inc. All rights reserved.

doi:10.1016/j.amjsurg.2006.04.021


2/10

It is important to have an understanding of the dangers ofradiation to the fetus. At 2 to 8 weeks post-conceptual age, therisk of radiation exposure is miscarriage, mental retardation,and malformations. At 8 to 15 post-conceptual weeks, the riskof radiation exposure is neuronal development, mental retar-dation, and small head size. Somatic effects such as mental

retardation have dose thresholds in the range of 5 to 10 rem[35]. The excess risk for childhood cancer is estimated at.06%/1 rem [6]. While this risk is small, it is reasonable toavoid radiation exposure when possible. Use of MR, whenavailable, instead of CT, allows for imaging diagnoses to bemade without use of ionizing radiation. When MR is notavailable, it is reasonable to perform CT scans if the radi-ation exposure is kept to a minimum (i.e., perform the scanonly once, with optimal oral preparation and intravenouscontrast).

Elective procedures should be delayed until after delivery.The risks of general anesthesia are least during the secondtrimester, when organogenesis is complete and risk of inducing

preterm labor is minimal, so semi-elective procedures shouldbe delayed until this time. Recent reports suggest that the riskof fetal wasting and teratogenicity from gastrointestinal oper-ations during pregnancy are minimal [79].

General Guidelines for Surgery During PregnancyNon-obstetrical general surgery is not rare and may be

required in approximately 1 of 500 pregnancies [1,10].However, surgery is always very stressful and anxiety-producing for the pregnant woman, even if the outcome issuccessful. Thoughtful and comprehensive preoperativecounseling about dangers to the fetus is an important com-ponent of care. Consultation and frequent communicationwith obstetrical colleagues is crucial. It is important toremember that physiologic changes during pregnancy alterthe maternal response to stress. Preoperatively, maintenanceof adequate hydration, availability of blood for transfusion,and maternal blood oxygenation and pH to avoid acidosisshould be ensured. Deep venous thrombosis (DVT) prophy-laxis with intermittent pneumatic compression devicesshould be employed and fetal monitoring should be donethroughout the perioperative period. Tocolytics should beadministered only for documented or perceived contrac-tions, not prophylactically.

Intraoperatively, the patient should be placed in the slightleft lateral position to prevent uterine compression of thevena cava and left iliac vein. Monitoring of maternal bloodgases should be considered, especially for laparoscopic pro-cedures as CO2 insufflation can induce maternal hypercap-nia, which can lead to fetal hypercapnia, tachycardia, andhypertension [11]. Measures should be taken to avoid aspi-ration as the pregnant patient is at increased risk of aspira-tion due to decreased gastrointestinal motility and intra-abdominal organ compression. Progesterone also has arelaxant effect on smooth muscle, diminishing esophagealsphincter competency. For laparoscopic surgery, open ac-cess using the Hasson technique will minimize potentialinjury to the fetus and port entry sites should be placedabove the level of the uterus. Low-pressure pneumoperito-neum should be used [11]. For open procedures, the uterinesize, the specific surgical disorder, and the anticipated type

of surgery to be performed will determine the abdominalincision. The uterus should be manipulated as little as pos-sible. Fetal monitoring should be continued in the postop-erative period.

AppendicitisAppendicitis is by far the most common surgical emer-gency in the pregnant patient. It occurs once in every 1500to 2000 pregnancies, with approximately equal frequency ineach trimester [12]. Management of appendicitis duringpregnancy is a surgical emergency and perforated appendi-citis is the no. 1 surgical cause of fetal loss during preg-nancy. Women who are pregnant have the same risk ofdeveloping appendicitis as non-pregnant women. Pain in theright lower quadrant of the abdomen is the most commonpresenting symptom of appendicitis in pregnancy regardlessof gestational age [13]. The signs and symptoms of acuteappendicitis are similar to those in non-pregnant patients

and include anorexia, nausea, vomiting, and periumbilicalpain that migrates to the location of the appendix, althoughfever and leukocytosis are not clear indicators of appendi-citis in pregnancy [13]. Nausea and vomiting may be diffi-cult to distinguish from symptoms due to pregnancy, butlocalizing right lower quadrant tenderness remains a reliablesign.

Early during pregnancy, peritoneal irritation develops inthe right lower quadrant, but after the fifth month of gesta-tion, the appendiceal position and the site of pain are shiftedsuperiorly above the right iliac crest and the appendix tip isrotated medially by the gravid uterus. The tenderness alsobecomes less localized as distention of the abdomen lifts theperitoneum away from the inflamed appendix and cecum[14]. Nearly all patients with appendicitis will developright-sided abdominal pain, and tenderness is still the mostimportant clinical finding. Abdominal guarding, reboundtenderness, and referred tenderness occur in approximately70% of patients, but guarding is not as reliable a sign givenlaxity of the abdominal musculature. Rectal or pelvic ten-derness is not as common given cephalad movement of theappendix out of the pelvis due to the gravid uterus. In thelatter months of pregnancy, the enlarging uterus may inter-fere with the normal ability of the omentum and bowel towall off the inflammatory process. Fever is less common(25% of patients) and leukocytosis is difficult to interpret, asthis is normal in pregnancy. However, the presence of highband counts should be a clinical clue.

Physical examination on presentation remains the mostreliable diagnostic tool, but radiologic studies are some-times needed to rule out other causes of abdominal pain,such as ovarian torsion, ovarian cysts, degenerating fibroids,pancreatitis, pyelonephritis, urolithiasis, or biliary tract dis-ease. Ultrasound is a safe imaging method, and an accom-plished ultrasonographer may be able to locate a swollen orinflamed appendix and look for a periappendiceal abscess(Fig. 1). If an abnormal appendix is visualized, the speci-ficity of sonography is high. However, if the appendix is notvisualized, and no other etiology for the pain is found, thenother imaging is needed. In these cases MR imaging can behelpful (Fig. 2). MR imaging is felt to be safe for use inpregnancy [15]. According to the Safety Committee of the

224 S. Parangi et al. / The American Journal of Surgery 193 (2007) 223232


3/10

Society for Magnetic Resonance Imaging [16], MR imagingprocedures are indicated for use in pregnant women if othernon-ionizing forms of diagnostic imaging are inadequate, orif the examination provides important information thatwould otherwise require exposure to ionizing radiation (i.e.,x-ray, CT, etc.). According to the American College ofRadiology White Paper on MR Safety, Pregnant patientscan be accepted to undergo MRI scans at any stage ofpregnancy if, in the determination of a . . . designated at-tending radiologist, the risk-benefit ratio to the patient war-rants that the study be performed [17]. The White Paperfurther states that it is recommended that pregnant patientsundergoing an MRI examination provide written informedconsent to document that they understand the risk/benefitsof the MRI procedure to be performed, the alternative di-agnostic options available to them (if any), and that theywish to proceed [17].

CT can be reserved for complicated cases, or for loca-tions where abdominal MR imaging experience is limited. Itshould be stressed that in those situations where a diagnosissuch as appendicitis is suspected, and sonography is incon-clusive or nondiagnostic, and MR is not available, CT is abetter choice than subjecting the patient to either a delayeddiagnosis or a general anesthetic, which are both associatedwith a risk of spontaneous abortion.

A high index of suspicion is needed so an early diagnosiscan be made, since perforation can lead to a 20% to 25%rate of fetal loss and a 4% maternal mortality, whereasuncomplicated acute appendicitis only results in a fetalmortality of less than 5% [7,18].

A higher rate of negative appendectomy in pregnantcompared to non-pregnant patients is acceptable given thepotential for worse outcome with perforation. Diagnostic

laparoscopy is useful in equivocal cases, and has reducedthe rate of false positive appendectomy to 15% [18]. Ofnote, pyelonephritis is the most common misdiagnosis inpatients with acute appendicitis in pregnancy. Once appen-dicitis is suspected or diagnosed immediate surgical inter-vention is recommended to avoid perforation. There is no

role for non-operative management. Simple acute appendi-citis has very little maternal mortality rate and the risk offetal loss is low, but maternal and fetal complications esca-late with peritonitis.

Patients with acute appendicitis should receive preoper-ative antimicrobial therapy with a cephalosporin and anaer-

Fig. 2. MR diagnosis of appendicitis in a patient 13 weeks pregnant with

severe right lower quadrant pain in whom sonography failed to show the

appendix. Coronal (A) and axial (B) T2-weighted images show an enlarged

fluid-filled appendix measuring 9 mm in caliber (arrow). Note the increased

signal intensity in the mesoappendix consistent with inflammatory changes

(arrowheads). Gravid uterus (U). Mild acute appendicitis was confirmed

both at surgery and pathology. Reproduced with permission from Eyvazze-

deh et al [92].

Fig. 1. Sonographic diagnosis of appendicitis in a patient 20 weeks

pregnant with severe right lower quadrant pain and a white blood cell count

of 15.6. Sagittal sonogram demonstrates the enlarged inflamed appendix,

measuring 11 mm in transverse diameter. Acute appendicitis was found at

surgery. Four weeks later the fetus developed hydrops.

225S. Parangi et al. / The American Journal of Surgery 193 (2007) 223232


4/10

obic coverage. Laparoscopic appendectomy can be per-formed safely during the first two trimesters, but is difficultto perform when the uterus is above the umbilicus [19]. Inan open operation, a standard muscle splitting incisionplaced over the location of maximal tenderness can be used.Traditional teaching was that the incision is gradually

moved more laterally and cephalad to McBurneys point asthe pregnancy progresses. However, a recent prospectivestudy of pregnant women with appendicitis showed no sig-nificant change in the location of the appendix [20]. It isimportant not to place retractors medially against the uterinesurface since this can lead to uterine irritability and onset oflabor. In the case of suspected rupture with peritonitis amidline incision is often used and skin closure is not per-formed to avoid wound infections. An appendiceal abscesscan be treated by percutaneous drainage and antibiotics. Aninterval appendectomy can be performed at a later date, aslong as the patient improves with the initial drainage andantibiotic therapy.

Biliary Tract DiseasesBiliary tract disease is the second most common gastro-

intestinal disorder requiring surgery during pregnancy[18,21]. Pregnancy predisposes to gallstone formation andgallstones occur in approximately 7% of nulliparous womenbut in 19% of women with two or more pregnancies [22].Gallstones and sludge are most likely caused by biliarystasis, prolonged intestinal transit, and increased cholesterolsaturation of bile. The frequency of biliary colic duringpregnancy is controversial, and the recommended therapeu-tic approach is conservative. One to eight of 10,000 preg-nant women will suffer from acute cholecystitis and, whenrequired, invasive procedures are well tolerated, especiallywhen performed during the second trimester [23]. Maternaland fetal complications are uncommon and the likelihood offetal demise or preterm delivery is minimized when electiveoperations are done in the second trimester. Infection, pan-creatitis, gallbladder rupture, or inappropriate delays canlead to increased rates of fetal mortality [24].

The symptoms of biliary tract disease are very similar tothose seen in non-pregnant patients. Common symptomsinclude anorexia, nausea, and vomiting, along with abdom-inal pain in the midepigastrium, right upper quadrant, orshoulder. Right upper quadrant tenderness and a Murphyssign are important findings. Laboratory values may revealan elevated alkaline phosphatase or bilirubin level. Jaun-dice, abnormal transaminases, or hyperamylasemia can be asign of complicated biliary tract disease [25]. Differentialdiagnoses include appendicitis, pancreatitis, peptic ulcerdisease, pyelonephritis, and HELLP syndrome (Hemolysis,Elevated liver enzymes, Low Platelets) with hepatic rupture[26]. A right upper quadrant ultrasound should be per-formed and is accurate 97% of the time in diagnosingcholelithiasis. The ultrasonographic signs of acute cholecys-titis remain the same during pregnancy and include gall-bladder wall edema, pericholecystitis fluid, an ultrasono-graphic Murphys sign or biliary ductal dilatation [27]. Ifextrahepatic ductal stones are suspected, and ultrasoundfails to adequately demonstrate the extrahepatic duct, thenMR cholangiography can be performed. Endoscopic retro-

grade cholangiopancreatography (ERCP) with its associatedradiation exposure can be performed only in cases wheretreatment is needed for documented ductal stones. The dosefrom an ERCP in pregnancy can be kept to safe levels ofapproximately 310 mrad [28].

Initial management of biliary tract disease in the preg-

nant state includes discontinuing oral intake, and providingantibiotics and analgesia as well as adequate hydration.Patients who fail to respond to medical therapy or haverepeated bouts of biliary colic requiring hospitalizationshould undergo an operation, which is best deferred to thesecond trimester if feasible.

Laparoscopic cholecystectomy can be performed safelyin most pregnant patients, especially during the first 2 tri-mesters [7,24,29] and advantages include less pain and aquicker recovery compared to an open procedure. An openentry technique is probably safest, although use of the Ve-ress needle with alteration of the entry site has been reportedto be safe [7]. All port entry sites should be adjusted to

avoid injury to the gravid uterus. During laparoscopic cho-lecystectomy, the maternal end tidal CO2 or arterial CO2levels should be measured and temporary desufflation of thepneumoperitoneum should be performed if levels are rising,since hypercarbia can lead to fetal acidosis. Conversion toopen cholecystectomy should be considered if CO2 levelsare rising, there is poor visualization, or a prolonged pro-cedure is expected. Routine cholangiography is not advo-cated, but the biliary system can be assessed by intraoper-ative ultrasound. If choledocholithiasis is found or highlysuspected, this can be approached laparoscopically, with anopen common duct exploration, or with postoperativeERCP [30]. MR cholangiography and laparoscopic com-mon bile duct (CBD) exploration have also been reported asoptions in the management of CBD stones [31]. The appar-ent safety of ERCP with endoscopic sphincterotomy forstone extraction or stent insertion also has been addressed inthese reviews [32]. If endoscopic stone extraction is per-formed, the fetus should be shielded during fluoroscopy.

PancreatitisPancreatitis occurs more frequently in the third trimester

and the immediate postpartum period compared to earlier inthe pregnancy [10]. Management for the most part is non-operative, as in any other patient with pancreatitis [33]. Thegeneral principles of treatment remain the same, includingbowel rest with or without nasogastric suction, intravenousfluid and electrolyte replacement, and parenteral analgesics.Most cases of pancreatitis during pregnancy are the result ofgallstone disease [10]. Signs and symptoms are essentiallythe same as those in the nongravid state and can includesevere abdominal pain radiating to the flank associated withnausea, vomiting, and hyperamylasemia. Diagnosis can bedifficult as there is a physiologic increase in serum amylaseduring pregnancy. A serum amylase that is greater than 2times above the upper limit of normal suggests pancreatitis.Serum lipase also may be helpful in the differential diag-nosis. Important additional measures in the pregnant patientare fetal monitoring, attention to the choice of medication,avoidance of radiation to the fetus, and positioning themother to prevent potential deep venous thrombosis. Paren-



5/10

teral nutritional supplementation should be considered toprotect the fetus. Ultrasound can be used to visualize dilatedpancreatic ducts and pseudocysts and focal accumulationslarger than 2 to 3 cm but is limited by operator skill, obesity,and bowel dilatation [34]. CT scanning is generally notneeded unless severe necrosis of the pancreas is suspected

[34]. Surgical intervention is reserved for patients withinfected pancreatic necrosis of the pancreas, rupturedpseudocyst, severe hemorrhagic pancreatitis, or persistentbiliary obstruction, which is not amenable to ERCP clear-ance. Early surgical intervention is recommended for gall-stone pancreatitis in all trimesters [1,35]. This is supportedby evidence that more than 70% of patients with gallstonepancreatitis will relapse before delivery [33]. Both laparo-scopic and open cholecystectomy have been performedsafely for gallstone pancreatitis throughout gestation [3537]. Perioperative fetal monitoring and low pneumoperito-neum pressures are suggested [35]. Although ERCP has aclear role in managing this condition in nongravid patients,

its use in pregnancy is limited because of radiation exposureto the fetus [38,39]. To avoid radiation, videoendoscopy andultrasound guidance are being developed for use in ERCPduring pregnancy [38]. Antibiotics are not recommendedfor patients with gallstone pancreatitis [34]. Managementof pancreatic pseudocysts in pregnancy remains contro-versial. Endoscopic stenting and percutaneous drainagehas not been shown to be effective for pseudocystsgreater than 5 cm [40]. As in nongravid patients, pseudo-cysts less than 5 cm in diameter tend to resolve sponta-neously.

TraumaPregnancy can be complicated by trauma such as motor

vehicle accidents, falls, or assaults. The approach to thepregnant patient who suffers blunt or penetrating abdominaltrauma should follow the principles of Advanced TraumaLife Support (ATLS) used for all patients. The mothermust be properly stabilized in order to protect the fetus.Close attention to airway, breathing, and circulationtheABCs of trauma managementremains the most impor-tant principle. In addition, fetal monitoring should be insti-tuted promptly and not delayed until the patient reaches theobstetric area of the hospital [41]. Fetal monitoring shouldcontinue for at least 24 to 48 hours if there are frequentuterine contractions, vaginal bleeding, abdominal tender-ness, postural hypotension, or fetal heart rate abnormalities.Fetal death is more likely with greater severity of maternalinjury and with mechanisms of injury such as ejection froma vehicle, motorcycle and pedestrian collisions, or assaults.Maternal death, maternal tachycardia, or abnormal fetalheart rate are all significant risk factors for increased fetaldeath [42,43].

The first step in fetal monitoring is the assessment offetal heart tones by Doppler or ultrasonography. Monitoringshould only continue if fetal heartbeat is present. Gesta-tional age should then be determined. This is most accu-rately performed by ultrasound. Electronic fetal monitoringshould only be continued in a viable fetus (at least 24 to 26weeks of gestation and 500 g) because no obstetric inter-vention will alter the outcome of a pre-viable fetus.

It is important to initiate monitoring as early as possibleafter maternal stabilization because most placental abrup-tions occur shortly after trauma. Placental abruption is as-sociated with at least 8 uterine contractions per hour formore than 4 hours and, after trauma, carries a 65% to 75%risk of fetal mortality. Significant placental abruption re-

quires immediate delivery of the fetus [42,44,45]. Fetalmonitoring can be discontinued after the first 4 to 6 hours ifthere are no complications during this interval since mostplacental abruptions occur shortly after trauma [42,4446].

Both ultrasound, using the FAST technique (FocusedAbdominal Sonography for Trauma), and abdominal CTscanning are important tools in the evaluation of the preg-nant trauma patient. The sensitivity and specificity of ab-dominal ultrasonography in pregnant trauma patients is sim-ilar to that seen in non-pregnant patients [47]. Ultrasound isespecially useful for detecting fetal distress, while CT candemonstrate uterine rupture and retroperitoneal hemorrhageas well as concurrent evaluation of other organs in the preg-

nant trauma patient [43]. A Kleihauer-Betke test may showevidence of fetomaternal hemorrhage and is recommended forRh-negative patients [10]. Blood transfusion, if necessary,should be cross-matched; if time is of the essence, noncross-matched O negative blood should be given to avoid antibodiesto Rh and sensitization in future pregnancies.

Intestinal ObstructionIntestinal obstruction is the third most common non-

obstetric reason for laparotomy during pregnancy (follow-ing appendicitis and biliary tract disease). It complicates 1in 1500 to 3000 pregnancies and is caused most commonlyby adhesions.

Its incidence increases as pregnancy progresses withmost cases occurring in the third trimester [10], with fewcases in the first trimester, and the remainder split almostequally between the second trimester and 6 weeks followingdelivery [4850].

Acute abdominal pain and vomiting and obstipation fromintestinal obstruction in pregnancy can be caused by adhe-sions, volvulus, intussusception, hernias, or neoplasm.

Intussusception from non-Hodgkins lymphoma is infre-quently diagnosed during pregnancy. The diagnosis of in-testinal obstruction is confirmed with a serial acute abdom-inal series. Volvulus should be suspected when there is asingle, grossly dilated loop of bowel. Persistent abdominal

pain aggravated by changes in position and by increases ofintra-abdominal pressure should always be investigated,even when a bulge or specific hernial defect is not clinicallyappreciable. Ultrasound can sometimes demonstrate thehernia defect. Physicians caring for the pregnant womanmust be aware that all abdominal conditions can occurdespite the pregnant condition. The management of bowelobstruction in pregnancy is essentially no different fromtreatment of non-pregnant patients and includes decompres-sion, intravenous hydration, and timely surgery [5155].

Splenic Artery AneurysmsSplenic artery aneurysms are quite rare, but they are

more common in women. Rupture of a splenic artery aneu-rysm is a catastrophic event, most commonly associated



6/10

with pregnancy and usually presents as sudden unexpectedshock or death. Half of the cases of rupture occur in patientsless than 45 years of age and a quarter of all cases are inpregnant women, usually in the third trimester or duringlabor. They are usually asymptomatic until rupture, al-though occasionally they are recognized by vague symp-

toms such as left upper quadrant or epigastric pain. In somecases, an audible bruit over the left hypochondrium can beappreciated or the aneurysm can be seen on plain x-ray ofthe upper abdomen as a calcified ring with a central lucentarea to the left of the first lumbar vertebral body. They canalso be identified on ultrasound or abdominal CT scan. Iffound, splenic artery aneurysms should be treated electivelyto avoid rupture, with splenectomy and resection of theartery, exclusion of the aneurysm or angiographic emboli-zation [56]. If rupture is suspected, immediate laparotomyshould be undertaken with ligation of the splenic artery andresection of the aneurysm and splenectomy. As in the non-pregnant patient, pneumococcal vaccine should be given 2

weeks prior to elective splenectomy or immediately follow-ing emergent splenectomy.

Hepatic LesionsPregnancy is associated with increased growth and risk

of rupture of hepatic adenomas. Hepatic adenomas are usu-ally solitary, but multiple lesions have been reported. Theassociation between oral contraceptives or other hormonetherapies and the development of adenomas is well estab-lished. The risk of rupture during pregnancy probably re-lates to the expanded blood volume and an increase invenous blood pressure. Liver hemangiomas are also relatedto estrogen, and pregnancy may stimulate enlargement orincrease the risk of rupture. Most patients can be treatedconservatively with frequent sonographic monitoring of thefetus and the hemangioma.

Adenomas greater than 5 cm in size should be resected;those smaller than 5 cm should be observed with serialultrasounds and resected if rapid growth is noted [57,58].There are no reports of maternal mortality from resection.Women with nonresected adenomas require close postpar-tum follow-up [57]. Surgical intervention is indicated incases of worsening symptoms, rapidly growing lesions,Kassabach-Merritt syndrome, and rupture [57,59].

Imaging of a liver mass during pregnancy is initiatedwith an ultrasound study. A cystic mass requires no furtherwork-up. A solid liver mass should be further evaluatedwith MR imaging without contrast. MR imaging has 100%sensitivity and 92% specificity for detecting a hemangioma.MR imaging can be followed with technetium-99m redblood cell scan to ascertain the diagnosis of hemangioma.CT scans are rarely used during pregnancy due to potentialharm to the fetus from ionizing radiation. When a heman-gioma is ruled out with the imaging techniques, percutane-ous needle biopsy may be necessary to establish a finaldiagnosis [57].

Acute fatty liver of pregnancy and the HELLP syndromeare rare but major disorders of pregnancy. Both are associ-ated with a history of preeclampsia and are generally seen inthe third trimester [60]. Subcapsular hemorrhage and he-patic rupture are unusual and potentially fatal complications

of the HELLP syndrome. A high index of suspicion andprompt recognition are keys to proper diagnosis and man-agement of affected patients. An aggressive multidisci-plinary approach is called for in these high-risk situations[61]. Surgical principles for control of bleeding are followedand techniques such as packing of the liver, deep mattress

sutures, or omentoplasty can be employed. In severe cases,liver transplantation has been successfully performed [62,63].

HemorrhoidsHemorrhoids in pregnancy are due to increased circulat-

ing volume, increased venous congestion caused by com-pression of the superior rectal veins by the pregnant uterus,as well as the relaxing effect of progesterone on the smoothmuscle in the walls of the veins [10]. Hemorrhoids canpresent with bleeding, prolapse, mucoid discharge, pruritus,and rectal discomfort. It is important to exclude other causesof these symptoms such as inflammatory bowel disease,anal fissure, and carcinoma of the colon, rectum, or anus.

Sigmoidoscopy and colonoscopy can be done safely inpregnancy [32,64]. Treatment is non-operative in mostcases and includes dietary fiber, psyllium, stool softeners,increased fluid intake, avoidance of straining, and hemor-rhoidal analgesics. Rubber band ligation can be performedfor internal hemorrhoids. If the hemorrhoids are severelyprolapsed or have associated ulceration, severe bleeding,fissure, or fistula and symptoms fail to respond to conser-vative measures, hemorrhoidectomy should be considered.Thrombosed external hemorrhoids can be treated with sim-ple clot extraction or if straightforward with excision of thethrombosed external hemorrhoids, which reduces thechance for recurrence.

Inflammatory Bowel DiseaseMost pregnant women with a history of inflammatory

bowel disease have uneventful pregnancies and exacerba-tions of disease can be controlled with medical therapy. It israre for the new onset of inflammatory bowel disease to bediagnosed during pregnancy [65]. The new diagnosis ofCrohns disease in pregnancy is difficult as the symptomsare often nonspecific and are similar to those seen in normalpregnancy [65]. There is often a delay in diagnosis andtreatment, which contributes to a poor prognosis.

Many patients with a history of ulcerative colitis man-aged with ileal pouch anal anastomosis (IPAA) will becomepregnant. Long-term outcomes of pregnancy and vaginaldelivery in females with ulcerative colitis before and afterIPAA are positive [66]. Early intervention involving appro-priate radiographic studies, antiobiotic treatment, and sur-gical management is recommended in pregnant patientswith a history of IPAA [67].

When relapses of Crohns disease do occur during preg-nancy, they usually present during the first trimester. Ab-scess is less well controlled in pregnancy and there is ahigher frequency of free perforation. For this reason, pa-tients presenting with peritoneal signs should undergo op-eration without delay. Resection of the source of the sepsisand exteriorization of the bowel ends rather than anastomo-sis is recommended as an anastomotic leak can prove cat-astrophic in a pregnant woman, putting both the mother and



7/10

fetus at increased risk [68]. Imaging can start with ultra-sound, but frequently another modality is needed, such asMR or CT (Fig. 3).

A minority of pregnant women with ulcerative colitiswill need surgery for toxic megacolon [69,70]. In suchcases, a limited surgical procedure may be desirable toreduce the risk of maternal and fetal mortality. The blow-hole colostomy and loop ileostomy (Turnbull procedure)has been used successfully in the management of toxic

dilation of the colon complicating ulcerative colitis in preg-nancy. Completion proctocolectomy and ileal pouch-analanastomosis can be completed after delivery [71]. A suc-cessful 3-stage procedure involving subtotal colectomy withdiverting ileostomy during pregnancy, proctectomy with anileal J-pouch anal anastomosis after delivery, and ileostomyclosure last also has been reported [72].

Colorectal MalignancyColon cancer during pregnancy is very rare as these

tumors are uncommon before age 40 [73,74]. The majorityof cases of colorectal carcinomas in pregnant women arise

from the rectum [75]. This may simply reflect a detectionbias by a tendency toward rectal examinations during pre-natal care [76]. Delayed diagnosis is common because ofsimilarity between GI complaints common in pregnancyand early signs and symptoms of colon cancer. Digital rectalexamination, tests for occult blood, and flexible sigmoidos-copy followed by colonoscopy should be performed forcomplaints consistent with colonic disease. Digital rectalexamination and sigmoidoscopy can be expected to revealgreater than 80% of colorectal tumors in pregnant patients[77]. MR imaging has been used to diagnose colon cancer inadvanced pregnancy [78]. Hepatic ultrasound is a sensitivemodality for detecting liver metastases in pregnancy [80].Carcinoembryonic antigen (CEA), a useful tumor markerfor colon cancer, may be elevated during pregnancy andtherefore is of little value [75].

Treatment of colorectal cancer follows the same generalguidelines as for non-pregnant patients [79]. Primary surgi-cal treatment should be performed whenever it is indicated.Later in pregnancy, it is preferable to delay surgery to allowfetal maturation and delivery. Stage for stage the survivaldata are the same for pregnant patients and non-pregnantcontrols; however, diagnosis is often delayed due to preg-nancy-associated gastrointestinal symptoms masking cancersymptoms [79].

With respect to colon cancer, many authors recommendprimary surgical treatment during the first half of the preg-nancy because delaying treatment until after delivery mayresult in tumor spread. Therefore, in the first half of preg-nancy, primary resection and anastomosis are advised. Hys-terectomy is not necessary to safely perform colon or rectalresection so therapeutic abortion is not mandated [79]. If thecancer is stage I, II, or IV, the pregnancy may be carried toterm and the stoma may be closed later [80]. If the lesion isunresectable or is obstructing in nature, a colostomy shouldbe performed to help provide time for the fetus to reachviability [81,82]. Stage III carcinomas are treated with che-motherapy after delivery as in non-pregnant patients[83,84]. Hysterectomy is advised when the mothers life ex-pectancy is less than the time required for the fetus to reachviability, if the uterus is involved, or greater access to therectum is needed for a technically complete operation [82,85].

Fig. 3. Sonographic and MR diagnosis of Crohns flare in a patient 20

weeks pregnant with known Crohns disease and severe right lower

quadrant pain. Sonogram (A, B) shows thick-walled appendix (arrows),

thickened terminal ileum (arrowheads). (C) Coronal MR shows abnormal

terminal ileum (arrowhead) and a thickened appendix (arrow). However,

there was no stranding of the periappendiceal fat to suggest appendicitis,

therefore the patient was treated medically for a Crohns flare and was

discharged from the hospital the following day.



8/10

Postpartum colorectal surgery is recommended for pa-tients presenting in the second half of pregnancy [80,83].Delivery may be induced when the fetus is viable andtreatment may continue as in a non-pregnant patient [80].Elective cesarean section is often preferred because colonicresection and staging procedures can be done concurrently

[84]. If cesarean delivery is required for obstetric reasons,proceeding with resection of colon carcinoma after primarycesarean section should be considered if the patient is med-ically stable, no significant complication of cesarean sectionhas occurred, and exposure is adequate. Proctectomy shouldalways be delayed [80]. If surgery is delayed until thepostpartum period, it should be performed after the graviduterus and pelvic vascularity have regressed to improveaccessibility to the tumor and reduce the risk of bleedingand thromboembolic complications [8183,85]. Properstaging, including transrectal ultrasonography, can be per-formed while awaiting involution of the uterus [82].

Colon cancer in pregnancy is complicated by ovarian

metastases in up to 25% of cases [86]. Several authors havereported that 22% to 23% of women younger than 40 yearswith colorectal tumors have ovarian metastases [87,88].Because of the high incidence of metastases to the ovary,bilateral ovarian biopsies with frozen sections are recom-mended. Bilateral salpingo-oophorectomy (BSO) is per-formed when the ovaries are involved or if hysterectomy isdone for other indications [81]. However, Nesbitt et alreported that BSO at the time of resection during pregnancymay increase the chance of spontaneous abortion, particu-larly in the first trimester [85]. Instead, they recommendbilateral ovarian wedge biopsies with frozen sections andremoval of the ovaries only if there is evidence of tumor orif hysterectomy is performed for other reasons [85].

Rectal cancer presenting in pregnancy is managed some-what differently than colon cancer. During the first 20weeks of pregnancy, patients wishing to carry their preg-nancies to term may elect to have primary resection fol-lowed by chemotherapy after delivery [83]. If the patientchooses to terminate the pregnancy, she may be managed asa non-pregnant patient after therapeutic abortion. Stage IIand III tumors are treated with chemotherapy after resec-tion. During the second half of pregnancy, treatment iswithheld until after delivery. Rectal tumors below the pelvicbrim may interfere with vaginal delivery and necessitatecesarean delivery. In advanced rectal tumors, preoperativeradiation therapy may have some benefit after deliverywhile awaiting involution of the uterus [82]. Patients whohave liver metastases at diagnosis should be treated withchemotherapy [84].

Cancer complications such as hemorrhage, obstruction,or perforation may necessitate surgical intervention [79]. Inpatients presenting with bowel obstruction or perforation,decompressive measures should be used as an initial ther-apy. During the first half of the pregnancy in an emergencysituation (obstruction, perforation, hemorrhage), Walsh andFazio recommend resection and stoma [77,80]. Hartmannsoperation is recommended for patients in an emergent sit-uation presenting with rectal cancer early in pregnancy [80].Obstructing rectal tumors discovered late in the pregnancyshould be treated by proximal diversion followed by cura-tive resection several weeks after delivery [77]. Controversy

exists regarding cesarean section during laparotomy via aninfected peritoneal cavity in the setting of perforation [81].

Chemotherapy for colorectal cancer does not offer suf-ficient benefit to the mother to warrant the risk to the fetus[76]. Chemotherapy is contraindicated during the first tri-mester of pregnancy. Adjuvant chemotherapy can be em-

ployed late in pregnancy in a patient who has undergonecolorectal resection early in pregnancy [80]. Radiation ther-apy is contraindicated in all trimesters and should be re-stricted for use in rectal cancer in non-pregnant patients whodo not desire further pregnancies because of the resultingpermanent and irreversible sterility [80,89,90].

A cancer diagnosis during pregnancy is a challengingand potentially devastating situation for the pregnantwoman and her family, who are faced with simultaneouslife-giving and life-threatening processes [91]. In these sit-uations, close attention to the psychological needs of thepatient and her family is as important as meticulous medicalcare. An interdisciplinary team approach is recommended

with close collaboration between the obstetrician, surgeon,oncologist, neonatologist, and pediatrician. Involvement ofthe nursing staff, social worker, chaplain, and an ethicistmay be useful as well [91].

SummaryAll GI disorders can present during pregnancy, and in

fact .2% to 1.0% of all pregnant women require non-obstet-rical general surgery [1]. All of the clinical decision-makingskills of the experienced surgeon must come into play inorder to make the correct therapeutic decisions when eval-uating the pregnant patient with a GI disorder that poten-tially requires surgery. While in general the principles ofdiagnosing and treating a pregnant woman with an acutesurgical abdominal problem remain the same as those gov-erning the treatment of the non-pregnant patient, some im-portant differences are present and can pose problems. As ageneral rule the condition of the mother should always takepriority because proper treatment of surgical diseases in themother will usually benefit the fetus as well as the mother.

References[1] Malangoni MA. Gastrointestinal surgery and pregnancy. Gastroen-

terol Clin North Am 2003;32:181200.[2] Parry R, Glaze SA, Archer BR. The AAPM/RSNA Physics Tutorial

for Residents Typical patient radiation doses in diagnostic radiology.Radiographics 1999;19:1289302.[3] Otake M, Schull WJ. Radiation-related brain damage and growth

retardation among the prenatally exposed atomic bomb survivors. IntJ Radiat Biol 1998;74:15971.

[4] Otake M, Schull WJ, Lee S. Threshold for radiation-related severemental retardation in prenatally exposed A-bomb survivors: a re-analysis. Int J Radiat Biol 1996;70:75563.

[5] Pierce DA, Preston DL. Radiation-related cancer risks at low dosesamong atomic bomb survivors. Radiat Res 2000;154:17886.

[6] Doll R, Wakeford R. Risk of childhood cancer from fetal irradiation.Br J Radiol 1997;70:1309.

[7] Affleck DG, Handrahan DL, Egger MJ, Price RR. The laparoscopicmanagement of appendicitis and cholelithiasis during pregnancy.Am J Surg 1999;178:5239.

[8] Barone JE, Bears S, Chen S, et al. Outcome study of cholecystectomy

during pregnancy. Am J Surg 1999;177:2326.[9] Tracey M, Fletcher HS. Appendicitis in pregnancy. Am Surg 2000;66:5559.



9/10

[10] Holschneider C. Surgical diseases and disorders in pregnancy. In:Alan H, DeCherney MLN, MD, et al, editors. Current Obstetric andGynecologic Diagnosis and Treatment. 9th ed. New York: McGraw-Hill; 2003.

[11] Schirmer B, Kouretas, PC. Gallstone pancreatitis. In: Cameron J,editor. Current Surgical Therapy. 7th ed. Philadelphia: Mosby; 2001:52833.

[12] Al-Mulhim AA. Acute appendicitis in pregnancy. A review of 52cases. Int Surg 1996;81:2957.

[13] Mourad J, Elliott JP, Erickson L, et al. Appendicitis in pregnancy:new information that contradicts long-held clinical beliefs. Am JObstet Gynecol 2000;182:10279.

[14] Weingold AB. Appendicitis in pregnancy. Clin Obstet Gynecol 1983;26:8019.

[15] Shellock FG, Crues JV. MR procedures: biologic effects, safety, andpatient care. Radiology 2004;232:63552.

[16] Shellock FG, Kanal E. Policies, guidelines, and recommendations forMR imaging safety and patient management. SMRI Safety Commit-tee. J Magn Reson Imaging 1991;1:97101.

[17] Kanal E, Borgstede JP, Barkovich AJ, et al. American College ofRadiology White Paper on MR Safety: 2004 update and revisions.AJR Am J Roentgenol 2004;182:11114.

[18] Visser BC, Glasgow RE, Mulvihill KK, et al. Safety and timing of

nonobstetric abdominal surgery in pregnancy. Dig Surg 2001;18:40917.

[19] Firstenberg MS, Malangoni MA. Gastrointestinal surgery duringpregnancy. Gastroenterol Clin North Am 1998;27:7388.

[20] Hodjati H, Kazerooni T. Location of the appendix in the gravidpatient: a re-evaluation of the established concept. Int J GynaecolObstet 2003;81:2457.

[21] McKellar DP, Anderson CT, Boynton CJ, et al. Cholecystectomyduring pregnancy without fetal loss. Surg Gynecol Obstet 1992;174:4658.

[22] Gilat T, Konikoff F. Pregnancy and the biliary tract. Can J Gastro-enterol 2000;14(suppl D):55D9D.

[23] Kammerer WS. Nonobstetric surgery in pregnancy. Med Clin NorthAm 1987;71:55160.

[24] Curet MJ, Allen D, Josloff RK, et al. Laparoscopy during pregnancy.

Arch Surg 1996;131:54650.[25] Ordorica SA, Frieden FJ, Marks F, et al. Pancreatic enzyme activityin pregnancy. J Reprod Med 1991;36:359 62.

[26] Mayer IE, Hussain H. Abdominal pain during pregnancy. Gastroen-terol Clin North Am 1998;27:136.

[27] Reece EA, Assimakopoulos E, Zheng XZ, et al. The safety of ob-stetric ultrasonography: concern for the fetus. Obstet Gynecol 1990;76:13946.

[28] Tham TC, Vandervoort J, Wong RC, et al. Safety of ERCP duringpregnancy. Am J Gastroenterol 2003;98:30811.

[29] Abuabara SF, Gross GWW, Sirinek KR. Laparoscopic cholecys-tectomy during pregnancy is safe for both mother and fetus. JGastrointest Surg 1997;1:4852.

[30] Sungler P, Heinerman PM, Steiner H, et al. Laparoscopic cholecys-tectomy and interventional endoscopy for gallstone complicationsduring pregnancy. Surg Endosc 2000;14:26771.

[31] Tuech JJ, Binelli C, Aube C, et al. Management of choledocholithi-asis during pregnancy by magnetic resonance cholangiography andlaparoscopic common bile duct stone extraction. Surg Laparosc En-dosc Percutan Tech 2000;10:3235.

[32] Cappell MS. The safety and efficacy of gastrointestinal endoscopyduring pregnancy. Gastroenterol Clin North Am 1998;27:3771.

[33] Swisher SG, Hunt KK, Schmit PJ, et al. Management of pancreatitiscomplicating pregnancy. Am Surg 1994;60:75962.

[34] Fallon WF Jr, Newman JS, Fallon GL, et al. The surgical manage-ment of intra-abdominal inflammatory conditions during pregnancy.Surg Clin North Am 1995;75:1531.

[35] Cosenza CA, Saffari B, Jabbour N, et al. Surgical management ofbiliary gallstone disease during pregnancy. Am J Surg 1999;178:5458.

[36] Sen G, Nagabhushan JS, Joypaul V. Laparoscopic cholecystectomy in

third trimester of pregnancy. J Obstet Gynaecol 2002;22:5567.[37] Gouldman JW, Sticca RP, Rippon MB, et al. Laparoscopic cholecys-tectomy in pregnancy. Am Surg 1998;64:937.

[38] Simmons DC, Tarnasky PR, Rivera-Alsina ME, et al. Endoscopicretrograde cholangiopancreatography (ERCP) in pregnancy withoutthe use of radiation. Am J Obstet Gynecol 2004;190:14679.

[39] Kahaleh M, Hartwell GD, Arseneau KO, et al. Safety and efficacy ofERCP in pregnancy. Gastrointest Endosc 2004;60:28792.

[40] Eddy JJ, Lynch GE, Treacy DE. Pancreatic pseudocysts in pregnancy:a case report and review of the literature. J Perinatol 2003;23:6972.

[41] Kolb JC, Carlton FB, Cox RD, et al. Blunt trauma in the obstetric

patient: monitoring practices in the ED. Am J Emerg Med 2002;20:5247.

[42] Curet MJ, Schermer CR, Demarest GB, et al. Predictors of outcomein trauma during pregnancy: identification of patients who can bemonitored for less than 6 hours. J Trauma 2000;49:1824.

[43] Lowdermilk C, Gavant ML, Qaisi W, et al. Screening helical CT forevaluation of blunt traumatic injury in the pregnant patient. Radio-graphics 1999;19(spec no):S24355.

[44] Grossman NB. Blunt trauma in pregnancy. Am Fam Physician 2004;70:130310.

[45] Pearlman MD, Tintinalli JE, Lorenz RP. Blunt trauma during preg-nancy. N Engl J Med 1990;323:160913.

[46] Connolly AM, Katz VL, Bash KL, et al. WF. Trauma and pregnancy.Am J Perinatol 1997;14:3316.

[47] Goodwin H, Holmes JF, Wisner DH. Abdominal ultrasound exami-nation in pregnant blunt trauma patients. J Trauma 2001;50:68993.

[48] Watanabe S, Otsubo Y, Shinagawa T, et al. Small bowel obstructionin early pregnancy treated by jejunotomy and total parenteral nutri-tion. Obstet Gynecol 2000;96:8123.

[49] Coleman MT, Trianfo VA, Rund DA. Nonobstetric emergencies inpregnancy: trauma and surgical conditions. Am J Obstet Gynecol1997;177:497502.

[50] Connolly MM, Unti JA, Nora PF. Bowel obstruction in pregnancy.Surg Clin North Am 1995;75:10113.

[51] Sato N, Miki T, Toyonaga T, et al. [A case of herniation through adefect in the falciform ligament at late pregnancy]. Nippon GekaGakkai Zasshi 1996;97:78790.

[52] Gangi S, Sparacino T, Furci M, Basile F. Hernia of the posteriorlamina of the rectus abdominis muscle sheath: report of a case. AnnItal Chir 2002;73:3357.

[53] Joshi MA, Balsarkar D, Avasare N, et al. Gangrenous sigmoid vol-vulus in a pregnant woman. Trop Gastroenterol 1999;20:1412.

[54] John H, Gyr T, Giudici G, et al. Cecal volvulus in pregnancy. Case reportand review of literature. Arch Gynecol Obstet 1996;258:1614.

[55] Samara C, Tsikini A, Antoniou S, et al. Ultrasonographic and com-puted tomography manifestations of intussusception secondary toprimary non-Hodgkins lymphoma diagnosed in puerperium: reportof a case and review of the literature. Eur J Gynaecol Oncol 2002;23:56972.

[56] English JD. Spontaneous rupture of a splenic artery aneurysm in thethird trimester. Ir J Med Sci 1993;162:16970.

[57] Cobey FC, Salem RR. A review of liver masses in pregnancy and aproposed algorithm for their diagnosis and management. Am J Surg2004;187:18191.

[58] Ault GT, Wren SM, Ralls PW, et al. Selective management of hepaticadenomas. Am Surg 1996;62:8259.

[59] Farges O, Daradkeh S, Bismuth H. Cavernous hemangiomas of the

liver: are there any indications for resection? World J Surg 1995;19:1924.[60] Pereira SP, ODonohue J, Wendon J, et al. Maternal and perinatal

outcome in severe pregnancy-related liver disease. Hepatology 1997;26:125862.

[61] Sheikh RA, Yasmeen S, Pauly MP, et al. Spontaneous intrahepatichemorrhage and hepatic rupture in the HELLP syndrome: four casesand a review. J Clin Gastroenterol 1999;28:3238.

[62] Aldemir M, Bac B, Tacyildiz I, et al. Spontaneous liver hematomaand a hepatic rupture in HELLP syndrome: report of two cases. SurgToday 2002;32:4503.

[63] Reck T, Bussenius-Kammerer M, Ott R, et al. Surgical treatment ofHELLP syndrome-associated liver rupturean update. Eur J ObstetGynecol Reprod Biol 2001;99:5765.

[64] Abramowitz L, Sobhani I, Benifla JL, et al. Anal fissure and throm-bosed external hemorrhoids before and after delivery. Dis Colon

Rectum 2002;45:6505.[65] Goetler CE, Stellato TA. Initial presentation of Crohns disease inpregnancy: report of a case. Dis Colon Rectum 2003;46:40610.



10/10

[66] Hahnloser D, Pemberton JH, Wolff BG, et al. Pregnancy and deliverybefore and after ileal pouch-anal anastomosis for inflammatory boweldisease: immediate and long-term consequences and outcomes. DisColon Rectum 2004;47:112735.

[67] Aouthmany A, Horattas MC. Ileal pouch perforation in pregnancy:report of a case and review of the literature. Dis Colon Rectum 2004;47:2435.

[68] Hill J CA, Scott NA. Surgical treatment of acute manifestations of

Crohns disease during pregnancy. J R Soc Med 1997;90:64 6.[69] Kane S. Inflammatory bowel disease in pregnancy. Gastroenterol Clin

North Am 2003;32:32340.[70] Korelitz BI. Inflammatory bowel disease and pregnancy. Gastroen-

terol Clin North Am 1998;27:21324.[71] Ooi BS, Remzi FH, Fazio VW. Turnbull-Blowhole colostomy for

toxic ulcerative colitis in pregnancy: report of two cases. Dis ColonRectum 2003;46:1115.

[72] Toiyama Y, Araki T, Yoshiyama S, et al. Fulminant ulcerative colitisduring pregnancy successfully treated by three-stage operation. JGastroenterol 2004;39:3001.

[73] Cappell MS. Colon cancer during pregnancy. The gastroenterolo-gists perspective. Gastroenterol Clin North Am 1998;27:22556.

[74] Chan YM, Ngai SW, Lao TT. Colon cancer in pregnancy. A casereport. J Reprod Med 1999;44:7336.

[75] Skilling JS. Colorectal cancer complicating pregnancy. Obstet Gy-

necol Clin North Am 1998;25:41721.[76] Antonelli NMD, Deborah J, Katz VL, et al. Cancer in pregnancy: a

review of the literature. Part I. Obstet Gynecol Survey 1996;51:12534.[77] Medich DS, Fazio VW. Hemorrhoids, anal fissure, and carcinoma of

the colon, rectum, and anus during pregnancy. Surg Clin North Am1995;75:7788.

[78] Seidman DS, Heyman Z, Ben-Ari GY, et al. Use of magnetic reso-nance imaging in pregnancy to diagnose intussusception induced bycolonic cancer. Obstet Gynecol 1992;79:8223.

[79] Cunningham F, Gant NF, Leveno KJ, et al. Williams Obstetrics. NewYork: McGraw-Hill; 2001.

[80] Walsh C, Fazio VW. Cancer of the colon, rectum, and anus duringpregnancy. The surgeons perspective. Gastroenterol Clin North Am1998;27:25767.

[81] Shushan A, Stemmer SM, Reubinoff BE, et al. Carcinoma of thecolon during pregnancy. Obstet Gynecol Surv 1992;47:2225.

[82] Bernstein MA, Madoff RD, Caushaj PF. Colon and rectal cancer inpregnancy. Dis Colon Rectum 1993;36:1728.

[83] Ochshorn Y, Kupferminc MJ, Lessing JB, et al. Rectal carcinomaduring pregnancy: a reminder and updated treatment protocols. Eur JObstet Gynecol Reprod Biol 2000;91:2012.

[84] Komurcu S, Ozet A, Ozturk B, et al. Colon cancer during pregnancy.A case report. J Reprod Med 2001;46:758.

[85] Nesbitt JC, Moise KJ, Sawyers JL. Colorectal carcinoma in preg-nancy. Arch Surg 1985;120:63640.

[86] Matsuyama T, Tsukamoto N, Matsukuma K, et al. Malignant ovariantumors associated with pregnancy: report of six cases. Int J GynaecolObstet 1989;28:616.

[87] Pitluk H, Poticha SM. Carcinoma of the colon and rectum in patientsless than 40 years of age. Surg Gynecol Obstet 1983;157:3357.

[88] Recalde M, Holyoke ED, Elias EG. Carcinoma of the colon, rectum,and anal canal in young patients. Surg Gynecol Obstet 1974;139:

90913.[89] Cappell MS. Colon cancer during pregnancy. Gastroenterol Clin

North Am 2003;32:34183.[90] Mayr NA, Wen BC, Saw CB. Radiation therapy during pregnancy.

Obstet Gynecol Clin North Am 1998;25:30121.[91] Oduncu F, Kimmig R, Hepp H, et al. Cancer in pregnancy: maternal-

fetal conflict. J Cancer Res Clin Oncol 2003;129:13346.[92] Eyvazzadeh AD, Pedrosa I, Rofsky NM, et al. MRI of right-sided

abdominal pain in pregnancy. 2004;183:90714.


pat gastrointest quirurgica

Documents